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Screening Colonoscopy vs. Diagnostic Colonoscopy

If you are here today because you were sent to one of our providers for a “Screening Colonoscopy” or you have seen the physician and he/she recommends a colonoscopy, please read the form in its entirety. You need to be fully educated on the state and federal guidelines for reimbursement services.

The CMS “Screening Initiatives” passed in January 2011, dictates that patients undergoing a screening colonoscopy will not be held to their coinsurance or deductible responsibilities.

The definition of a “screening colonoscopy” per CMS guidelines is as follows: “A colonoscopy being performed on a patient who does not have any signs of symptoms in the lower GI anatomy PRIOR to the scheduled test.”

Any symptom, such as change in bowel habits, diarrhea, constipation, bleeding, anemia, etc., prior to the procedure and noted as a symptom by the physician in your medical record may change the benefit from a Screening to a Diagnostic Colonoscopy. We cannot change your medical record after you have been seen, nor can we change the fact you have had symptoms prior to your procedure.

Please note: If you had a colonoscopy within the last 10 years and the result indicated you had colon polyps, you may NOT be eligible for “screening initiative” benefits. Because if you have a prior history of polyps, your colonoscopy is now considered a “surveillance of the colon” and therefore may be considered diagnostic. You may have been healthy and had no symptoms since your last colonoscopy, but you have what is considered a pre-existing nature of polyps, and therefore, are not eligible to be classified as “screening.” However, if your last colonoscopy was 10 years ago or more, then you are eligible for a “screening colonoscopy,” regardless of history. It is your responsibility to know your insurance benefits. Please contact your insurance company with benefit questions prior to your procedure.

Please be advised that if you are a true “screening colonoscopy” and during the procedure your doctor finds a polyp or tissue that must be removed for pathological testing or if you are diagnosed with a GI problem, the procedure is no longer a “screening” and becomes “diagnostic.” Please be aware that any polyp that is found may be pre-cancerous and must be removed. Your insurance benefits may change. We make every effort to code correctly for your procedure with the correct modifiers and diagnoses. We make every effort to work with the facility to have the billing coded correctly as well. The correct coding of a procedure is driven by the physician and your medical history. It is not dictated by your benefit or the insurance company.

*Please note that these guidelines are not necessarily in line with our Providers’ belief for proper patient care, however they are upheld as required by CMS Policies and Procedures.